case STUDIES

Lauren S. Schlesselman, PharmD

Published Online: Thursday, February 1, 2007

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CASEONE:
While on rotation in an
ambulatory care clinic, a
pharmacy student is asked
to assess NW, a 67-year-old
woman, during her annual
physical examination. According
to NW's chart, she
has a history of hypertension,
type 2 diabetes (requiring insulin for the last 5 years),
and obesity. Despite repeated attempts to convince her to
quit, NW has continued to smoke 1 pack of cigarettes per
day for the last 40 years and has had "a few drinks with dinner"
for the last 25 years. NW's chart also states that her
current medications include furosemide, 40 mg by mouth
daily; ramipril, 5 mg by mouth daily; Neutral Protamine
Hagedorn insulin; and regular insulin. The vital signs done by
the nurse are documented as height, 5 feet 3 inches;
weight, 215 lb; body temperature, 98.6? F; blood pressure,
170/90 mm Hg; heart rate, 90 beats/min; and respiratory
rate, 16 breaths/min.

The pharmacy student checks the clinic computers for that
day's results. The results for NW show that her basic metabolic
panel and complete blood count are within normal limits,
except for a blood glucose level of 165 mg/dL. NW's fasting
lipid profile shows a total cholesterol level of 320 mg/dL,
a low-density lipoprotein level of 215 mg/dL, and a high-density
lipoprotein level of 30 mg/dL. Her Hgb A1c is reported as
9%. A 24-hour urine collection reveals 0.7 g of protein.

The pharmacy student's preceptor asks him to utilize the
7th Report of the Joint National Committee on Prevention,
Detection, Evaluation, and Treatment of High Blood Pressure
(JNC 7) guidelines to answer the following questions:

1. What is NW's goal blood pressure?

2. Is NW at her goal blood pressure?

CASE TWO:
JA, a diaphoretic 35-year-old
man with a history of
depression, presents to the
emergency department of
the local hospital via ambulance.
JA's roommate called
the ambulance when JA
began having episodes of
hallucinations, accompanied
by hyperreflexia and tremors. JA is well-known to the emergency
department staff due to frequent narcotic-seeking
behavior and illicit drug abuse.

JA's roommate suspected that JA had overdosed on prescription
medications. JA had refilled his prescription for fluoxetine
2 days earlier. When the roommate found the bottle,
which should have contained a month's supply, the bottle
was empty. The roommate also noticed that his own bottle
of meperidine was empty but should have had nearly 60
tablets remaining. The roommate admits that they had been
using cocaine shortly before JA's hallucinations and tremors
began.

JA is placed on a cardiac monitor and pulse oximeter. To
relieve his rigidity and agitation, 4 mg of intravenous
lorazepam is quickly administered. Due to the possibility of
prescription medication overdose, gastric decontamination
also is performed.

JA is admitted to the hospital for monitoring. His admission
orders include continuing lorazepam therapy and initiating
cyproheptadine 4 mg hourly for 4 hours, followed by 4
mg every 6 hours. Within 24 to 36 hours, JA's vital signs are
stabilized and his mental status has improved.

Considering JA's cocaine use and apparent fluoxetine and
meperidine overdose, what syndrome did the medical team
treat?

Dr. Schlesselman is an assistant clinical professor at the University of Connecticut School of Pharmacy.

CASE ONE: According to JNC 7, the guidelines recommend a goal blood pressure of 130/80 mm Hg for patients with diabetes. The
pharmacy student should inform the preceptor that NW is not at her goal blood pressure. NW should be reeducated about lifestyle modifications
and
have her medication therapy modified.

CASE TWO: JA presented with serotonin syndrome. This syndrome is caused by excessive serotonin due to drug interactions, overdose of
serotonergic
agents, or drugs of abuse that increase serotonin. In this case, JA's serotonin syndrome was caused by inhibition of serotonin reuptake by
fluoxetine,
meperidine, and cocaine, and increased serotonin release due to cocaine use. Common symptoms include autonomic dysfunction, mental
status changes, and neuromuscular abnormalities.